| Abstract|| |
Objective: The present study was undertaken to determine the safety, accuracy and clinical utility of ultrasound guided fine needle aspiration biopsy in the diagnosis of pancreatic masses.
Material and methods: Seventy-five patients with clinical and ultrasound suspicion of pancreatic carcinoma were aspirated using a twenty-two gauge, Teflon coated needle under ultrasound guidance. The masses ranged in size from 2.5 to 4.5 cm.
Results: This technique confirmed malignancy in 61 of the 70 cases of malignancy (87.1%). Thirty-nine patients including 14 patients with negative aspiration underwent surgery and out of the 14 aspirationnegative patients, five patients had chronic pancreatitis and nine patients had carcinoma. This was confirmed on histology of the biopsy specimen taken at laparotomy. Four patients developed mild abdominal pain after aspiration; one patient developed acute pancreatitis and recovered with conservative treatment. One patient developed peritonitis after aspiration, had extensive tumor of pancreas involving the duodenum and expired later on, after laparotomy.
Conclusion: Ultrasound guided fine needle aspiration biopsy of pancreas is a safe, reliable and accurate technique for the diagnosis of malignancy. It has a high diagnostic accuracy of 88%, sensitivity of 73% and a specificity of 100%. The predictive value of positive and negative results, is 100% and 35.71% respectively with a mortality of 1.3%.
Keywords: Pancreatic Carcinoma, Ultrasound-Guided Aspiration, Pancreas, Ultrasound, Biopsy
|How to cite this article:|
Javid G, Khan B A, Shah A, Khan M A, Gulzar G M, Khan B A. Role of ultrasound-guided percutaneous fine needle aspiration cytology in carcinoma of pancreas. Indian J Radiol Imaging 1999;9:159-63
An accurate diagnosis of pancreatic carcinoma is very important for decision-making regarding surgery and for prognosis. This is more so, since it is often difficult to ascertain if a pancreatic mass found at laparotomy is due to a pancreatic carcinoma or due to some other disease in the pancreas . Even the symptoms of carcinoma and chronic pancreatitis are so similar that they are not helpful in differentiating between the two conditions. Ultrasound cannot distinguish a benign from a malignant mass unless secondary signs of carcinoma are present (adjacent nodes or liver metastasis) . Procedures such as wedge biopsy and large bore needle biopsy at operation are inaccurate and hazardous . Duodenoscopy allows brush and juice cytology from the pancreatic duct; however the results have been disappointing and the techniques are not widely accepted ,.
|How to cite this URL:|
Javid G, Khan B A, Shah A, Khan M A, Gulzar G M, Khan B A. Role of ultrasound-guided percutaneous fine needle aspiration cytology in carcinoma of pancreas. Indian J Radiol Imaging [serial online] 1999 [cited 2021 Feb 26];9:159-63. Available from: https://www.ijri.org/text.asp?1999/9/4/159/28347
During recent years interventional ultrasound has become widely used with a great impact on patient management with respect to diagnosis and therapy. Many surgical procedures have been replaced by the more, gentle and less time consuming ultrasound guided aspiration, to the benefit of patients. Ultrasound guided aspiration of space occupying lesions in the abdomen and retroperitoneum is an increasingly common practice in oncology . In many cases it provides the opportunity for obtaining morphological diagnosis safely and rapidly. The present report describes the safety, reliability and accuracy of ultrasound guided fine needle aspiration biopsy in patients with suspected pancreatic malignancy.
| Materials & Methods|| |
Between September 1990 and November 1997, 210 patients were evaluated for various pancreatic disorders. Seventy-five consecutive patients with clinical, ultrasound (US) and computed tomography (CT) suspicion of pancreatic carcinoma underwent US guided aspiration of the pancreatic lesions 105 times. The group comprised of 48 men and 27 women who ranged in age from 40-71 years with a mean age of 56 years [Table - 1]. The most frequent complaint was epigastric pain radiating to the back in twenty-eight patients. Thirty patients had obstructive jaundice and six patients had palpable masses. Ascites was found in six patients while 25 patients had weight loss and anorexia in addition to other features. The size of the masses ranged from 2.5 - 4.6 cm in diameter. The masses were located in the head of the pancreas in 53 patients, in the body in 20 and in the tail in two [Table - 2].
A sterile puncture transducer (Aloka SSD 256: Aloka Tokyo) with a preset puncture area and guiding channel was used to locate the mass. A 22-guage beveled Teflon coated needle (Cool Bloomington Inc., USA) was used for aspiration. Following skin cleaning, the selected skin entrance site was anesthetized with a 2% lidocaine injection. The needle enclosed in a stylet, was inserted through the guiding channel to a point where the tip of the needle reached the center of the mass. The stylet was then removed, a 20ml syringe was attached to the hub of the needle and aspiration biopsy performed with back and forth movements of the needle under continuous negative pressure. The aspirated material was smeared and air-dried on clear glass slides and stained with May-Grunwald-Giemsa stain Three aspirations were done at one time. After the procedure, the patients were observed in a standard manner.
Cytological specimens were classified as negative, positive, suspicious or unsatisfactory. Smears that revealed unequivocal evidence of malignancy were categorized as "positive". Smears that showed rich cellular material but without evidence of malignancy were grouped as "negative". Smears showing findings suggestive but not absolutely diagnostic for malignancy, were categorized as "suspicious". Smears that revealed no cellular material were diagnosed as "unsatisfactory" .
The final diagnosis in 75 patients was pancreatic carcinoma in 70 and chronic pancreatitis in five [Table - 3]. Thirty-nine patients including 14 patients with negative aspiration of pancreatic masses staged as operable by CT criteria underwent laparotomy and biopsy of the resected specimen. In the remaining patients who did not undergo laparotomy, the final diagnosis of malignancy was made based on the following criteria:
(i) Demonstration of malignancy in the biopsy of lymph nodes, metastatic deposits or ascitic fluid
(ii) Serial US or CT scan showing progression of masses, or development of metastases elsewhere in the body;
(iii) Death by malignancy during follow-up.
The final diagnosis of chronic pancreatitis in five cases was confirmed on the basis of the following criteria:
a) operative findings compatible with benign diseases in all five patients
b) clinical and biochemical improvement on follow-up for more than 4 years and
c) no progression of disease by imaging techniques.
Diagnostic results of USGA were evaluated statistically and sensitivity, specificity, overall accuracy, predictive positive value and negative predictive value were obtained . Results were considered significant if p value <0.05.
| Results|| |
A total of 105 US guided aspiration biopsies were performed in 75 patients suspected to have pancreatic carcinoma. Sixty-one patients had pancreatic carcinoma on FNAB, but a total of 70 were confirmed to have carcinoma either at surgery or by examination of lymph nodes or the ascitic fluid. Therefore, nine patients had a false negative result on FNAB giving a sensitivity of 73%, specificity of 100%, predictive value of positive results, 100% and predictive value of negative results, 35.71%. The overall accuracy of FNAB to enable correct diagnosis of all pancreatic lesions was 88%. The diagnostic yield in relation to the size of the mass was not significant (p>0.1) [Table - 4].
Four patients (5.3%) developed minor complications, which consisted of mild pain at the site of aspiration, which required analgesics for forty-eight hours. One patient (1.3%) developed acute pancreatitis characterized by severe pain and hyperamylasemia and recovered with conservative treatment. One patient (1.3%) developed signs of peritonitis and showed no response to conservative treatment and was subjected to a laparotomy that revealed an extensive pancreatic tumor infiltrating the duodenum. The patient developed septicemia and expired later.
The FNAB was useful in the clinical management in all 61 patients in whom it was positive. Of the 70 patients with malignancy, 36 had no surgery after the FNAB results. These patients were deemed unresectable or were unfit for surgery and were spared exploratory surgery. The remaining 34 patients underwent palliative surgery or radical resection.
| Discussion|| |
The study shows that US guided aspiration biopsy of pancreatic masses is a reliable and highly accurate method, enabling correct diagnosis of malignancies. The overall accuracy of cytological evaluation was 88% with a sensitivity of 73%, specificity of 100%, positive predictive value of 100% and a negative predictive value of 35.71%. Our results are comparable with other studies [Table - 5].
False negative results are one of the main disadvantages of aspiration. False negative results were obtained in nine patients. Unsuccessful aspiration should prompt repeat aspiration and if the repeat procedure is unsuccessful, surgical biopsy should be performed. The reliability of negative FNAB is quite low when evaluating patients for suspected pancreatic malignancy. Therefore, a negative result in such a situation should not preclude surgery. Some authors are of the view that the results of FNAB correlate with size and site of the lesion in the pancreas . Although our results showed no significant correlation between the size of the lesion and the results of aspiration, the results did show a positive trend with the increasing size of lesion.
False negative result may be the result of sampling error for a misguided needle, small mass size, or cytological error from a very well-differentiated necrotic tumor. Negative or equivocal diagnoses need further diagnostic maneuvers, frequently including surgery to make a definitive diagnosis .
The value of a positive biopsy lies in its ability to avoid a diagnostic laparotomy in patients who are unfit for radical resection or staged inoperable by CT criteria. A positive biopsy is also valuable in those patients who require surgery enabling the surgeon to go ahead with planned radical or palliative surgery.
We had one mortality in a patient who had developed peritonitis following aspiration and had extensive pancreatic tumor infiltrating to the duodenum at laparotomy. Review of literature revealed one fatality from pancreatitis in a patient with pancreatic carcinoma . One patient in our study developed acute pancreatitis. Similar complications have been reported by others [11,17] while some have not experienced any complications ,.
CT guided aspiration biopsy of pancreatic masses has also been reported with good results . Endoscopic ultrasound guided fine needle aspiration of pancreatic masses is also being increasingly used with encouraging results but needs expertise .
Ultrasound guided fine needle aspiration biopsy is cost effective, does not need much expertise and is an efficient means of establishing histological diagnosis of pancreatic carcinoma. It causes minimal discomfort to the patient, infrequent, minimal complications, contributes to early diagnosis and obviates the need for diagnostic laparotomy in patients with advanced carcinoma, or in those who are at high-risk for surgery.
| References|| |
|1.||Forsgren L, Orell S. Aspiration cytology in carcinoma of the pancreas. Surgery 1973; 73: 38-42. [PUBMED] |
|2.||Hill MC: Pancreatic sonography: an update P-1 in Saunders RC (ed): Ultrasound Annals 1982 New York: Raven Press, 1982. |
|3.||Hovdenak N, Lees WR, Pereira J, Beilly J, Cotton PB: Ultrasound guided percutaneous fine needle aspiration cytology in pancreatic cancer. British Medical Journal 1982; 285:1183-1184. |
|4.||Osnes M, Serck - Hanssen A. Kristensen 0, Swensen T, Aune S, Myren J: Brush cytology in patients with primary and secondary malignancies of pancreas. Gut 1979; 20:279-84. |
|5.||Cotton PB, Kizu M: Endoscopic pancreatography and pure pancreatic juice, In: Glass GBJ, ed. Progress in Gastroenterology. Vol 111 New York: Grune and Stratton 1997; 967-89. |
|6.||Freble WJ: Fine needle aspiration biopsy. A review Hum Path 1983; 14: 8-9. |
|7.||Zarger SA, Khuroo MS, Mahajan R, Ghulam Mohd. Jan, Shah P: Ultrasound guided fine needle aspiration biopsy of gall bladder masses. Radiology 1991; 179 275-277, |
|8.||Galen RS, Gambino Sr. Beyond normality. The predictive value and efficiency of medical diagnosis New York, John Wiley & Sons 1975. |
|9.||Hancke S, Horn HH, Koch F. Ultrasonically guided percutaneous fine needle biopsy of the pancreas Surgery Gynecology Obstet 1975; 140: 361-4. |
|10.||Tylen U, Arnesjo B, Lindberg LG, Lunderquist A. Akerman M: Percutaneous biopsy of carcinoma of pancreas guided by angiography. Surg Gynecol Obtet 1976; 142: 737-9. |
|11.||Mc Loughling MJ, Ho CS, Lange B, Mc Hattie J, Tao LC: Fine needle aspiration biopsy of malignant lesions in and around the pancreas. Cancer 1978; 41: 24139. |
|12.||Itoh K, Yamana T, Kasahara K, Koike M, Nakamura A, Hayaski A, Kimura K et al. Definitive diagnosis of pancreatic carcinoma with percutaneous fine needle aspiration biopsy under ultrasonic guidance. Am J of Gastroenterol 1979; 71: 469-76. |
|13.||Linder S, Balsjo M, Sudelin P, Von Rosen A: Aspects of percutaneous fine needle aspiration biopsy in the diagnosis of pancreatic carcinoma, Am J Surg 1997, 174: 303-6. |
|14.||Tillou A, Schwartz MR, Jordan PH. Percutaneous needle biopsy of the pancreas: When should it be performed? World J Surg 1996; 20: 283-287. |
|15.||Enayati PG, Traverso LW, Galagan K et al. The meaning of equivocal pancreatic cytology in patients thought to have pancreatic cancer. Am J Surg 1996, 171: 525-28. |
|16.||Evans WK, Ho CS, McLaughlin MK, Tao LC: Fatal necrotizing pancreatitis following fine needle aspiration biopsy of the pancreas. Radiology 1981; 141:61-2. |
|17.||Tao LC, Ho CS, Mc Laughlin MJ, McHattie J: Percutaneous fine needle aspiration biopsy of pancreas. Acta Cytol 1978; 22: 215-20. |
|18.||Beazley RM: Needle biopsy diagnosis of pancreatic cancer. Cancer 1981; 47: 1685-7. |
|19.||Sperti C, Pasquali C, Di Prima F, Rugge M, Pertin P, Costantino V. Percutaneous CT-guided fine needle aspiration cytology in the differential diagnosis of pancreatic lesions. Ital J Gastroenterol 1994; 26: 126-31. |
|20.||Chang KJ, Nguyen P, Erickson RA, Durbin TE, Katz KD: The clinical utility of endoscopic ultrasound guided fine needle aspiration in the diagnosis and staging of pancreatic carcinoma. Gastrointest Endosc. 1997; 45: 387-93. |
|21.||Faigel DO, Ginsberg GG, Bentz JS, Gupta PK, Smith DB, Kochman ML: Endoscopic ultrasound guided real time fine needle aspiration biopsy of the pancreas in cancer patients with pancreatic lesions. J Clin Oncol 1997;15:1439-43. |
|22.||Chang KJ, Katz KD, Durbin TE, Erickson RA, Butler JA, Lin F: Endoscopic ultrasound guided fine needle aspiration. Gastrointest Endosc 1994; 40: 694-9. |
Department of Gastroenterology,Gilistan Manzil, Amira Kadal-190001, Srinagar
Source of Support: None, Conflict of Interest: None
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5]